Treatment for heroin addiction is available, for a price

It’s when your health insurance also runs dry, the halfway house has kicked you out, you’ve lost your friends and your mom won’t help anymore.

You’re living on the streets, sleeping in alleyways or in the woods and you are hungry ... for food and the next heroin high.

It’s time to either get help to treat the disease or turn yourself over to the drug and possibly death.

Lisa Guerrieri, who admitted prostituting herself for drugs, hit that bottom point after previously going through nine stints in rehabilitation facilities.

The number of times Lisa was in rehab isn’t an option for most people. They don’t have the health insurance or cash to keep returning to a rehab facility for in-patient or out-patient treatment. And experts say, 30 days of rehab just isn’t enough to teach an addict the tools needed to live without heroin.

Lisa’s parents helped pay the 20-year-old’s way — or their health insurance did.

While Pennsylvania law mandates health insurers cover at least 30 days of inpatient drug and alcohol detox and rehabilitation treatment, it doesn’t mandate that everyone has health insurance.

Come January, though, 3 million to 5 million people nationwide with drug and alcohol problems could become eligible for insurance coverage under the Affordable Care Act. Treatment professionals hope that the change will close some loopholes and gaps that leave thousands of Pennsylvanians thousands of dollars short of breaking their addiction.

Pennsylvania Act 106 of 1989 requires insurers to cover up to seven days of detoxification a year, up to four times in an insured person’s lifetime; at least 30 days of rehabilitation a year, and up to 90 days in a lifetime; and at least 30 “units” of outpatient or partial hospitalizations per year, or up to 120 “units,” in a lifetime.

State Rep. Gene DiGirolamo said in his 18 years as a legislator, insurance companies have unsuccessfully tried to have Act 106 overturned or overwritten.

But even with that law, some fall through the cracks — like Ashley Elder.

STRUGGLES

Ashley was a happy teen until early 2001, mom Roberta Lojack said. That’s when her moods changed. When rumors of drug use got back to her mother in February of that year, she went looking in Ashley’s room and found the telltale signs of addiction — straws and tin foil and heroin baggies.

She and her ex-husband took their daughter to hospital after hospital, hoping someone would admit her for treatment. But since she had health insurance, they were told they needed to find a private facility.

Eventually, Ashley was placed in an outpatient counseling program three days a week. But after less than two months, the counselor told Lojack to save her benefits until they could help Ashley. Lojack still has no idea what that meant.

In September 2001, after experiencing heroin withdrawal at home, Ashley was admitted to an inpatient facility for a 28-day stay. She was there for only nine, when the facility told Lojack that Ashley had completed its program — and their insurer wouldn’t pay for more treatment. Lojack said the facility refused her offer to pay out of pocket for the full 28 days.

Ashley was discharged on a Saturday and Lojack had set up an evaluation at another rehab facility for that Monday. The weekend seemed positive, with a family birthday party, long talks about the future and Ashley volunteering to make dinner Sunday night. Later that night, Ashley told her mother she loved being back home and covered her face in kisses before heading to bed.

On Monday morning, Lojack found her 18-year-old daughter lying in bed, the TV remote still in her hand. Ashley was dead.

Ten days later, Lojack received a letter from the insurer. After consulting with the rehab facility’s physician, the insurer’s physician adviser decided that inpatient care was “not medically necessary.”

THE RULES

In addition to such determinations, insurers can make 30 days the maximum length of treatment, even though the law makes it the minimum, according to Dr. William Lorman, the chief clinical officer for the Livengrin Foundation, a treatment facility in Bensalem.

State law allows publicly funded managed care for some uninsured people, but they are often eligible for no more than 14 days of inpatient treatment. And there’s a third group of Pennsylvanians who can’t get help, because they’re uninsured and don’t qualify for public assistance.

The Bucks County Drug and Alcohol Commission tries to fill as much of the gap as possible. Each year, it sets aside money to help fund treatment for those who can’t otherwise afford it. Diane Rosati, the commission’s acting executive director, said funds are available for different types of treatment, from outpatient to counseling to halfway houses to detox and rehabilitation. Last year, the commission set aside $556,453 for non-hospital rehabilitation and detoxification funding.

People seeking treatment can go into a rehab center for an assessment to determine which program they need most and whether the treatment is covered by insurance or publicly funded managed care. If neither, the commission is called upon. It covers “one treatment experience” at a residential facility per year, Rosati said. There is no limit to the number of outpatient visits or counseling the commission supports.

Still, it’s not enough. Many more people can’t afford to get treatment.

“There is no illness currently being treated that will be more affected by the Affordable Care Act than addiction,’’ said Tom McLellan, CEO of the nonprofit Treatment Research Institute and President Barack Obama’s former deputy drug czar. “That’s because we have a system of treatment that was built for a time when they didn’t understand that addiction was an illness.”

Only about 10 percent of the 23 million Americans with alcohol or drug problems now receive treatment, according to the National Survey on Drug Use and Health. About a quarter of those not getting treatment have no insurance coverage.

In Pennsylvania, an estimated 2.5 percent of those who need drug abuse treatment don’t receive it, according to the Substance Abuse and Mental Health Services Administration statistics. A national drug survey based on data from 2008 and 2009 estimates 7.45 percent of Pennsylvanians abuse illicit drugs, which is more than 900,000 residents.

Today, those without insurance include many lower- and middle-income people who don’t get the benefit from their employer — businesses provide coverage for about 50 percent of Americans. Their income is just a bit too high to qualify for Medicaid and too low to afford to buy their own health care policy.

The new law will provide subsidies to help many buy private health insurance. The government is also pressing states to expand their Medicaid programs to include more working poor people. If 20 states expand their Medicaid programs — roughly the number now planning to do so — an additional 3.8 million prospective patients with addiction problems would get insurance, according to analysis by the Associated Press. If almost all of the states eventually decide to expand, as federal officials predict, the ranks of the newly insured with addiction problems could reach 5.5 million.

The Department of Public Welfare, which oversees Medicaid in Pennsylvania, issued a fact sheet earlier this year raising concerns about the fiscal responsibility of expanding coverage. And published reports indicate lawmakers are not interested. The DPW estimates that federal guidelines would add 800,000 new people into the state’s medical assistance program, including people previously not covered, or who were dropped or chose to drop their employers’ plan because of the availability of Medicaid.

But ensuring coverage isn’t a panacea.

Thirty days in Livengrin’s outpatient facility costs about $12,000, according to Lorman, the chief clinical officer there. Even if the cost is covered by insurance, there are still deductibles or coinsurance payments.

For those attempting to stay clean through outpatient programs, expenses can add up, too. One Livengrin program offers outpatient sessions three times a week at $120 a day. Even a person whose insurance covers the expense can end up paying as much as $50 of that as a copay or in coinsurance.

Some facilities, such as Livengrin, try to provide funds for scholarships. Each year, Livengrin’s board of directors makes $500,000 worth of scholarships available. Initially, they’d offered $300,000, Lorman said, but that was used up in just six months.

Despite all the help available, it’s the lucky few who have good enough coverage to make it.

ALWAYS RECOVERING

Lisa’s parents, Maria Guerrieri and Tim Husbands, said their private insurance plan helped pay the costs of treatment, minus co-pays. And through the Affordable Care Act, they were able to keep Lisa on their insurance plan even though she was no longer a student.

But it cost them greatly and, by the end, they feared the insurer was going to reach its limit with Lisa. And the financial output wasn’t just the $5,000 spent on copays. They also paid about $5,000 in legal fees, thousands of dollars in travel and room rentals for the halfway houses, and covered Lisa’s costs of living while she was in treatment. Maria Guerrieri said without insurance, they would have spent more than $100,000.

Maria Guerrieri said her family was living in a fantasy world after Lisa was released from prison, where she went after being busted for prostitution and had to detox cold turkey. No painkillers or heroin substitutes to help her through withdrawal.

They were thinking, “Oh, it’s great, she’s coming back and our lives will be normal again.”

But within 72 hours, Lisa was using drugs again.

Last June, her parents sent Lisa to The Recovery Place in Fort Lauderdale. A month later, she was just beginning a stay at a halfway house to learn life skills all over again. But she failed a drug test.

“As loved ones, parents, you have to get out of the way and they have to hit that bottom,” Guerrieri said. “And, unfortunately, sometimes that bottom is death.”

Maria Guerrieri said when Lisa called after being booted out of the halfway house, they told her she was on her own. They weren’t going to help anymore. They gave her some phone numbers and told her she was going to have to check herself into another facility, if she could find one that would take her.

She did. And because she took the step to get herself into a state facility to detox, her parents agreed to pay for it. Then, after passing a urine test, she was admitted back into the halfway house.

Now, Lisa lives in Florida. She has a strong support base there, with a sponsor, counselors and recovery facilities. She has been clean for nine months.

Once, she almost relapsed, when she returned to Bucks County and was once again around the people with whom she used to abuse drugs. She called her sponsor in Florida to help her through her cravings.

“Recovery is hour by hour, day by day, and it doesn’t end,” Maria Guerrieri said. “There is no cure. And I’m in recovery. The family is in recovery.”

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